Accreditation and Regulatory Advisor

Indiana University Health; Portland (IN); On-site; USD 95,000 - 125,000; Full time

Job summary

Indiana University Health seeks an Accreditation & Regulatory Advisor for Critical Access Hospitals. Based near IU Health Frankfort Hospital with travel to facilities, you’ll guide accreditation readiness, interpret regulatory requirements, and lead improvement efforts to ensure safe patient care.

You will educate leaders, coordinate mock surveys, and develop corrective action plans while supporting multiple facilities across the system.

Qualifications

• Bachelor's degree required.
• 4-6 years of relevant experience.
• CPHQ or comparable certification within two years of employment.
• Interfacility travel for surveying and in-state overnight stays required.
• Current Indiana health professional license or eligible licensure.

Responsibilities

• Serve as primary accreditation and regulatory resource for assigned Critical Access Hospitals.
• Interpret accreditation standards, state/federal regulations, and compliance requirements.
• Coordinate survey readiness activities including mock surveys and readiness assessments.
• Lead onsite accreditation surveys and coordinate activities during survey events.
• Develop, monitor, and track corrective action plans for findings or gaps.
• Prepare written responses to agencies and ensure timely follow-up actions.
• Evaluate new services/workflows for regulatory compliance prior to implementation.
• Partner with leaders to identify improvement opportunities and restore compliance.
• Communicate regulatory changes, impacts, and action plans to leaders.
• Provide regular readiness updates to facility and system leadership.

Skills

Regulatory knowledge

Stakeholder communication

Education & training

Travel readiness

Education

Bachelor's Degree

Job description

Accreditation & Regulatory Advisor (Critical Access Hospitals)

The Accreditation & Regulatory Advisor serves as a subject matter expert in accreditation, regulatory compliance, and survey readiness across IU Health's Critical Access Hospitals. This position is responsible for facilitating accreditation and regulatory compliance activities within assigned facilities while providing readiness support and consultation to additional IU Health facilities as needed.

Working collaboratively with operational leaders, clinical teams, and key stakeholders, the advisor promotes a culture of continuous survey readiness and regulatory compliance. The role provides education, consultation, and expert guidance regarding accreditation standards, regulatory requirements, and compliance best practices to support safe, high-quality patient care.

While the role is currently based out of IU Health Frankfort Hospital, flexibility may be considered regarding the home-base location based on the selected candidate's geographic location and organizational needs. Regular interfacility travel is required to support survey readiness, accreditation activities, and regulatory compliance initiatives.

Schedule: Monday-Friday, Day Shift

Key Responsibilities

• Serves as the primary accreditation and regulatory compliance resource for assigned Critical Access Hospitals and provides interfacility support throughout the IU Health system.
• Acts as a trusted advisor to leaders and stakeholders by interpreting accreditation standards, state and federal regulations, and organizational compliance requirements.
• Plans, coordinates, and facilitates survey readiness activities, including mock surveys, tracers, education sessions, and readiness assessments.
• Leads onsite accreditation and regulatory surveys, coordinating activities before, during, and after survey events to ensure successful execution.
• Develops, coordinates, and monitors comprehensive corrective action plans in response to survey findings, deficiencies, or identified compliance gaps.
• Prepares written responses to regulatory agencies and accrediting organizations and ensures timely completion of all required follow-up actions.
• Proactively evaluates new or revised services, programs, workflows, and physical spaces to assess regulatory and accreditation compliance requirements prior to implementation.
• Partners with operational and clinical leaders to identify opportunities for improvement and restore compliance when regulatory risks or deficiencies are identified.
• Analyzes regulatory changes and communicates impacts, recommendations, and action plans to leaders and stakeholders.
• Provides regular readiness and compliance updates to facility and system leadership, including assessment of compliance risks and mitigation strategies.
• Serves as the facility liaison for communications with the Indiana Department of Health and applicable accrediting organizations.
• Promotes a culture of continuous readiness through education, coaching, collaboration, and process improvement activities.
• Participates in systemwide regulatory and accreditation initiatives, special projects, and performance improvement efforts.

Qualifications

• Bachelor's Degree is required.
• Requires 4-6 years of relevant experience.
• CPHQ or other comparable healthcare regulatory certification endorsed by IU Health System Regulatory Affairs required within two years of employment.
• Interfacility travel for surveying and in-state overnight stays is required.
• Requires current state of Indiana license as a health care professional (e.g., Registered Nurse with an active Registered Nurse (RN) license in the state of Indiana or an active Nurse Licensure Compact (NLC) RN license, Respiratory Therapist, Pharmacy or Rehabilitation license).

We are an equal opportunity employer. IU Health does not discriminate on the basis of race, color, religion, sex, sexual orientation, age, disability, genetic information, veteran status, national origin, gender identity and/or expression, marital status or any other characteristic protected by federal, state or local law. We will ensure that individuals with disabilities are provided reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. Please contact us to request accommodation.